Development of a routine bedside CYP2C19 genotype assessment program for antiplatelet therapy guidance in a community hospital catheterization laboratory.

Genotype based personalized antiplatelet therapy in the setting of percutaneous coronary intervention (PCI) has been studied in clinical trials. Despite the demonstrated risk associated with CYP2C19 loss-of-function (LoF) carriage in clopidogrel-treated PCI patients, real-world implementation of genotyping for PCI has been low. The goal of the current study was to provide CYP2C19 genotype information to the interventionalist prior to the completion of the catheterization to facilitate immediate personalized antiplatelet therapy. Routine personalization of P2Y12 inhibitor therapy for PCI in a community hospital cardiac catheterization laboratory by POC genotyping with the SpartanRx system was first offered in February 2017. A best practice advisory (BPA) based on the Clinical Pharmacogenetics Implementation Consortium Guideline for CYP2C19 genotype and clopidogrel therapy was placed in the electronic health record prescription medication ordering system. By December 2019, 1,052 patients had CYP2C19 genotype testing, 429 patients underwent PCI with genotype guided antiplatelet therapy, and 250 patients underwent PCI without genotype testing and received antiplatelet therapy at the discretion of the treating physician. BPA compliance was 93. 87% of LoF allele carriers were prescribed ticagrelor or prasugrel whereas 96% of non-LoF allele carriers were prescribed clopidogrel. The genotyping results were available within 1 h and made immediately available for decision making by the interventional cardiologist. POC CYP2C19 genotyping is feasible in a community hospital catheterization laboratory and is associated with high rate of best practice compliance.Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT03040622.

Acute Progressive retro-peritoneal hematoma in COVID19 patients with sub cutaneous ecchymosis.

Introduction: and importance: COVID19 is a multifunction disease where hematological disorders are reported. Coagulopathy is seen in these patients, indicated by thromboembolic events. Case presentation: We present case of 11 COVID19 who were presented with localized skin ecchymosis lesions in different areas of the body and retroperitoneal hematoma in the posterior wall of the abdomen and chest. Clinical discussion: Increased INR and bleeding and ecchymosis in Corona patients require discontinuation of anticoagulants and, FFP, essential and tri amino injections are needed. Conclusions: Diagnosis and management of hematoma is important to avoid fatality.

Acute retroperitoneal hematoma following severe Covid-19 and the use of anticoagulants.

Introduction: and Importance: Severe COVID19 patients under anticoagulant therapy are at the risk of developing hematoma. Case presentation: We present case of 11 COVID19 who were presented with localized skin ecchymosis lesions in different areas of the body and retroperitoneal hematoma in the posterior wall of the abdomen and chest. Clinical discussion: Cases of hematoma with severe COVID19 patients under anticoagulant therapy are reported in several case studies, particularly in geriatric population with the previous history of blood and/or cardiac disorders. Conclusion: These patients should be carefully monitored for hematomas by skilled nurse and practitioner and timely treated and monitored.

Uterine artery embolization technique for treatment of a huge multi myomatous uterus in a virgin woman.

Introduction: Uterine artery embolization is a non-surgical method performed for large and numerous fibroids to preserve the fertility. Case presentation: The patient is a 36-year-old virgin woman with menometrorrhagia, abdominal pressure, constipation, bilateral abdominal pain, frequent urination and a compressive effect on the intestines was reported to our center. She was diagnosed with uterine fibroids. Discussion: Because the type of uterine masses and possibility of uncontrollable bleeding during myomectomy and hysterectomy, uterine vascular embolization by supra selective angiography to preserve the uterus was performed. Due to fever, pain and vaginal discharge, she was hospitalized again and hysterotomy was performed without any reported complications. Conclusion: Uterine artery embolization is a safe method, however reduction and loss in ovarian function can be seen with the treatment. Measurement of follicle stimulating hormone and anti-Müllerian hormone before and after the treatment is important.

The effect of training on variability and accuracy of overhand throwing in children with Down syndrome.

OBJECTIVE: People with Down syndrome (DS) have higher variability in their motor skills compared to other counterparts without intellectual disability. Given that the effect of physical training on the variability and accuracy is unclear, the purpose of this study was to examine the effect of nine sessions of overhand throwing training on the variability and accuracy of overhand throwing in children with DS. METHODS: Twenty-seven children with DS randomly assigned to experimental and control groups. In the pretest, two groups threw the tennis ball three times to the fixed target. Absolute error (AE) and the normalized root mean square (NoRMS) of segmental couplings of shoulder-elbow (NoRMS 1) and elbow-wrist (NoRMS 2) calculated from the scores of throwing and kinematics data, respectively. Then the experimental group participated in overhand throwing training for nine sessions. After that, the post-test was taken and ten days later, the retention test performed with pretest conditions. RESULTS: The results of two-way ANOVA with repeated measures on AE values showed the experimental group in the post-test and retention phases was more accurate than the control group. Also, AE values of the experimental group in the post-test and retention phases were significantly lower than the pretest. The results of two-way ANOVA with repeated measures showed that NoRMS 1 in the experimental group was significantly lower than control group in the post-test and retention phases. CONCLUSION: It seems the overhand throwing training can reduce the variability and increase the accuracy of overhand throwing in children with DS.

Unilateral repair of tracheoesophageal fistula with dilatation of incomplete subglottic stenosis.

A case of TEF along with subglottic stenosis in a patient as a result of prolong intubation. We performed left unilateral tracheal repair to avoid injury to left recurrent laryngeal nerve followed by endoscopic balloon repair of stenosis. Due to critical condition of the patient and COVID-19 infection, she expired.

Review of psychological trauma: theory, practice, policy and research.

We present a concise state-of-the-art review of psychological trauma and post-traumatic stress disorder (PTSD) for mental health practitioners. This article is also set to present the nature of traumatic incidents, their common presentation, their disruptions to normal psychological and biological functioning, and the negative health care impact of untreated incidents. Originally, the trauma response to extreme life events and PTSD was conceptualized as normal responses to overwhelming situations. However, in the last few years, there has been an increase in the acceptance of the idea that exposure to a traumatic situation/stimulus may not be sufficient to explain the development of PTSD. In addition, the individual vulnerability factors play a significant role in understanding this condition. In principle, this paper also focuses on the associative relationship between social support and psychological trauma because of methodological review. Hence, due to the paucity of such types of studies, this review starts with the findings and different aspects considered on the nature of social support, and then the general outcomes of this association. Furthermore, the relationship between support and human physiology is also presented. To further strengthen the objectives in review, the methodological issues and limitations are discussed in each section. Finally, this review article concludes the evaluation of the research specific to psychological trauma and social support in the field of combat, sexual abuse, and battering.

Effects of calcium level and source, formic acid, and phytase on phytate degradation and the microbiota in the digestive tract of broiler chickens.

BACKGROUND: Diet acidification, dietary calcium (Ca) level, and phytase supplementation are known influences on the microbial community in the digestive tract and on phosphorus (P) utilization of broiler chickens. Effects of dietary factors and microbiota on P utilization may be linked because microorganisms produce enzymes that release P from phytate (InsP6), the main source of P in plant feedstuffs. This study aimed to detect linkages between microbiota and InsP6 degradation by acidifying diets (i.e., replacing Ca carbonate (CaCO3) by Ca formate or adding formic acid to CaCO3-containing diets), varying Ca levels, and supplementing phytase in a three-factorial design. We investigated i) the microbial community and pH in the digestive tract, ii) prececal (pc) P and Ca digestibility, and iii) InsP6 degradation. RESULTS: All factors under investigation influenced digesta pH and the microbiota composition. Predicted functionality and relative abundance of microorganisms indicated that diets influenced the potential contribution of the microbiota on InsP degradation. Values of InsP6 degradation and relative abundance of the strains Lactobacillus johnsonii and Lactobacillus reuteri were correlated. Phytase supplementation increased pc InsP6 disappearance, with differences between Ca levels, and influenced concentrations of lower inositol phosphate isomers in the digestive tract. Formic acid supplementation increased pc InsP6 degradation to myo-inositol. Replacing CaCO3 by Ca-formate and the high level of these Ca sources reduced pc InsP6 disappearance, except when the combination of CaCO3 + formic acid was used. Supplementing phytase to CaCO3 + formic acid led to the highest InsP6 disappearance (52%) in the crop and increased myo-inositol concentration in the ileum digesta. Supplementing phytase leveled the effect of high Ca content on pc InsP6 disappearance. CONCLUSIONS: The results point towards a contribution of changing microbial community on InsP6 degradation in the crop and up to the terminal ileum. This is indicated by relationships between InsP6 degradation and relative abundance of phosphatase-producing strains. Functional predictions supported influences of microbiota on InsP6 degradation. The extent of such effects remains to be clarified. InsP6 degradation may also be influenced by variation of pH caused by dietary concentration and solubility of the Ca in the feed.

Delayed presentation of left traumatic diaphragmatic hernia with displacement of spleen and stomach to left hemi thorax.

We presented a case of late onset of left traumatic diaphragmatic hernia with displacement of spleen and stomach to the left hemi thorax, a year after the trauma. Gastric and respiratory complications along with herniation should be immediately managed, in order to reduce the risk of cardiac arrest and mortality.

A systematic review of prevalence of Depression in Iranian patients.

BACKGROUND: Depression is a common mental health disorder which has become a global public health issue. It constitutes around 35 to 45% of mental health problems in Iran and covers 8% to 20% of population of Iran. Therefore, the present study aimed to determine the prevalence of depression among the Iranian patients through systematic review and meta-analysis. METHOD: For the present study information were searched in Web of Science, Scopus, PubMed, Google Scholar, and in Iranian databases including Iran Medex, SID, MedLib, Scientific Information Database, MagIran, using the following keywords: "depression", "prevalence" and Iran. The data from these databases were analyzed through meta-analysis (random effects model). Heterogeneity among the results of the studies was examined by I2 index. Beck Depression Inventory (BDI), Depression Anxiety and Stress Scale-21 (DASS-21), General Health Questionnaire-28 (GHQ-28), and Geriatric Depression Scale (GDS) were used in this study, and statistical analyses were performed using STATA Ver.16. RESULTS: A total of 46 studies conducted in Iran based on a sample size of 2960 individuals was found during the time period of 2010 and 2018. Prevalence of depression among Iranian patients was estimated to be 34.26 (95% CI, 24.12% - 44.10%). Thus, the findings indicated that there exists a moderate prevalence of depression which is continuously growing. CONCLUSION: The prevalence of depression in Iran is moderate and growing which is alarming as it may turn out to be a massive increase in incidence rate of depression in coming years. This indicates a greater risk for Iranian population and calls for effective measures to be taken to control the mental health problems among Iranian patients.

Effects of vorapaxar on clot characteristics, coagulation, inflammation, and platelet and endothelial function in patients treated with mono- and dual-antiplatelet therapy.

BACKGROUND: Vorapaxar is indicated with standard antiplatelet therapy (APT) in patients with a history of myocardial infarction (MI) or peripheral arterial disease (PAD). OBJECTIVES: To evaluate the comparative effects of vorapaxar on platelet-fibrin clot characteristics (PFCC), coagulation, inflammation, and platelet and endothelial function during treatment with daily 81 mg aspirin (A), 75 mg clopidogrel (C), both (C + A), or neither. METHODS: Thrombelastography, conventional platelet aggregation (PA), ex vivo endothelial function by ENDOPAT, coagulation, platelet activation/inflammation marked by urinary 11-dehydrothromboxane B2 (UTxB2 ) and safety were determined in patients who were APT naïve (n = 21), on C (n = 8), on A (n = 29), and on A + C (n = 23) during 1 month of vorapaxar therapy and 1 month of offset. RESULTS: Vorapaxar had no effect on PFCC, ADP- or collagen-induced PA, thrombin time, fibrinogen, PT, PTT, von Willebrand factor (vWF), D-dimer, or endothelial function (P > .05 in all groups). Inhibition of SFLLRN (PAR-1 activating peptide)-stimulated PA by vorapaxar was accelerated by A + C at 2 hours (P < .05 versus other groups) with nearly complete inhibition by 30 days that persisted through 30 days after discontinuation in all groups (P < .001). SFLLRN-induced PA during offset was lower in APT patients versus APT-naïve patients (P < .05). Inhibition of UTxB2 was observed in APT-naive patients treated with vorapaxar (P < .05). Minor bleeding was only observed in C-treated patients. CONCLUSION: Vorapaxar had no influence on PFCC measured by thrombelastography, coagulation, or endothelial function irrespective of APT. Inhibition of protease activated receptor (PAR)-1 mediated platelet aggregation by vorapaxar was accelerated by A + C and offset was prolonged by concomitant APT. Vorapaxar-induced anti-inflammatory effects were observed in non-aspirin-treated patients.

Which source and level of dietary sodium is appropriate for broiler chickens reared in a high-altitude area?

This study investigated effect of increasing level of dietary sodium using sodium bicarbonate or sodium chloride on growth performance, mortality, characteristics of carcass, organs and tibia, calcium and phosphorus of serum in broilers reared in a high-altitude area (1,700 m above sea level). A total of 588 Ross 308 male broiler chicks were used in seven treatments, six replicates per treatment of 14 birds per each from 1 to 38 d of age. Seven dietary treatments consisted of a basal diet (with 0.16% sodium and 0.23% chloride), top-dressed for six diets to give three supplementary levels of sodium (0.07%, 0.14% and 0.21%) from sodium bicarbonate (respectively by 0.26%, 0.52% and 0.78%) or sodium chloride (respectively by 0.18%, 0.36% and 0.54%), resulting in seven diets with total sodium and chloride levels of 0.16% and 0.23%, 0.23% and 0.23%, 0.30% and 0.23%, 0.37% and 0.23%, 0.23% and 0.33%, 0.30% and 0.44%, 0.37% and 0.55% respectively. Increasing sodium level improved feed conversion ratio (FCR) linearly and quadratically. However, when FCR was calculated without adjusting for feed intake of mortalities, the enhanced sodium level did not improve this parameter. Increasing sodium level via sodium chloride enhanced ascites mortality, total mortality, relative weight of heart and right ventricle linearly. Increasing sodium level reduced serum calcium and enhanced serum phosphorus linearly; however, there was a linear tendency to increase tibia ash when sodium level was enhanced by sodium bicarbonate (p = 0.08) or sodium chloride (p = 0.07). Increasing sodium level via sodium bicarbonate tended (p = 0.08) to reduce tibia strength linearly. In conclusion, a diet with 0.16% sodium and 0.23% chloride is enough for broiler chicken reared in a high-altitude area, and increasing dietary sodium level via sodium chloride has detrimental effect on survivability of broiler in such condition.

Pre-programming in overhand throwing of children with Down syndrome: role of the generalized motor program.

OBJECTIVE: It is unclear whether slowness and higher reaction time of individuals with Down syndrome (DS) are because of inability to pre-program and using the generalized motor program (GMP) or not. So, the purpose of this study was to examine the consistency of relative timing as a fixed feature of a GMP in overhand throwing with changing the distance to target as a varied feature. METHODS: Fifteen individuals with DS (age = 13 ± 2 y) and a control group of 12 individuals without intellectual disability (ID; age = 13 ± 2 y) were asked to throw a tennis ball to a fixed target from three distances of 2, 2.75, and 3.25 m, respectively. Instant of occurrence of the following discrete variables was recorded by motion analysis: initiation of elbow extension, maximum shoulder angular velocity, maximum elbow angular velocity, and maximum resultant hand velocity. RESULTS: Results of two-way analysis of variance test did not show any significant difference in any of the relative kinematic variables in distances and groups (p > 0.05). CONCLUSION: It seems that individuals with DS are able to motor preprogram and they use a GMP to overhand throwing from different distances as well as those without ID. Also, slowness and reaction time are unrelated to pre-programming and GMP as it relates to overhand throwing.

Multiple-enzyme supplementation on digestive traits, carcass characteristics, blood lipid parameters and growth performance of broilers fed a wheat-based diet.

OBJECTIVE: A trial was conducted from 11 to 42 d post-hatch to investigate the effectiveness of the supplementation of a multiple-enzyme preparation (Natuzyme Plus) in a wheat-based diet on digesta viscosity, pH and microbial population, villus morphology, feed passage time, nutrient retention, carcass characteristics, blood lipid parameters and growth performance of broiler chickens. METHODS: Three hundreds 10-d-old male Ross 308 chicks were allocated to three diets with five replicates of 20 birds per replicate. Dietary treatments were i) a wheat-based diet (W), ii) W+Natuzyme Plus (WN; 500 mg/kg of the diet), and iii) a corn-based diet (C). RESULTS: Birds fed on the C diet had higher average daily gain (ADG, p<0.01), villus height (VH, p<0.01), total tract apparent retention (TTAR) of nitrogen (NT, p<0.01) and ether extract (EE, p<0.01), nitrogen-corrected apparent metabolizable energy (AMEn, p<0.05), relative weight (RW, % of body weight) of carcass (p<0.05), blood concentration of triglyceride (TG, on d 40 [p<0.01]), total cholesterol (TC, on d 22 [p<0.05]) and low density lipoprotein (LDL, on d 22 [p<0.01] and 40 [p<0.05]), and also lower feed conversion ratio (FCR, p<0.01), digesta viscosity (p<0.01), count of coliforms (p<0.01) and Escherichia coli (p<0.01) and epithelium thickness (ET, p<0.05) than those fed on the W diet. ADG, FCR, VH, ET, TTAR of NT and EE, RW of carcass, blood concentration of TG (on d 40), TC (on d 22) and LDL (on d 22 and 40) values of the WN diet did not show a significant (p>0.05) difference compared to those of the C diet. Compared to those of the W diet, the WN diet showed the higher count of Lactobacilli and lower count of coliforms (p<0.01) and digesta viscosity (p<0.01). CONCLUSION: In general, the results of this study showed that Natuzyme Plus supplementation in a wheat-based diet can be appropriate to achieve a comparable growth performance in broiler chickens to those given the C diet probably through improving digesta viscosity, VH, ET, TTAR of NT and EE, AMEn, count of Lactobacilli and coliforms.

The effects of physical therapy on exaggerated muscle tonicity, balance and quality of life on hemiparetic patients due to stroke.

OBJECTIVE: To determine the effects of physical therapy on balance, exaggerated muscle tonicity and quality of life on patients with hemiparesis. METHODS: This quasi-experimental study was conducted in 2011 among male hemiparetic patients secondary to stroke, at a physiotherapy centre in Neyshabur, Iran. Twenty-four patients were randomly assigned to two equal groups representing the cases and the controls.The cases were assigned to do the practical protocol for 4 weeks.To collect the data, Berg Balance Scaling, Modified Ashworth Scale, Barthel Activities of Daily Living Index and demographic questionnaires were used. Paired and un-paired t-tests were used to analyse data. All analyses were done on SPSS 16. RESULTS: The two groups were similar before intervention. Post-test analysis showed that the average balance and quality of life significantly improved (p<0.001) among the cases, and the quadriceps muscle tonicity decreased (p<0.001). Among the controls, there was no significant change between pre-test and post-test readings. CONCLUSIONS: Physical therapy can enhance balance and quality of life of hemiparetic patients and reduces their exaggerated muscle tonicity.

Evaluation of patency of arteriovenous fistula and its relative complications in diabetic patients.

PURPOSE: To study the arteriovenous fistula patency, duration of its maintenance, and its relative complications. MATERIALS AND METHODS: One hundred and thirty patients who had undergone hemodialysis during five years (1996 to 2001) were included in this study. The patency rate and complications, including paresthesia, pain induced by ischemia, venous hypertension, infection, erythema, and edema, were assessed. Data were recorded in the pre-designed questionnaire and statistically analyzed using t test. RESULTS: Mean ± standard deviation age of the patients was 58.08 ± 11.73 years (range, 18 to 80 years). Most of the fistulas were created at the left bracheocephalic (58 subjects). Side-to-side technique was the mostly applied technique (99.2%). The fistula patency was 100%, 92.64%, 89.48%, 84.38%, and 83.61% at year 1 to 5, respectively. There was a significant negative correlation between the subjects' age and maintained patency (P = .02). However, no significant difference was observed between the maintained patency and other variables, including gender, location of the fistula, and the type of the technique applied for creation of the fistula (P > .05). CONCLUSION: Diabetes does not have a negative impact on the rate of patency and its duration in arteriovenous fistula. However, further investigations on a larger population are recommended.

Acute renal failure as an initial manifestation of multiple endocrine neoplasia (MEN) type 1.

Multiple endocrine neoplasia (MEN) is a group of heritable syndromes characterized by aberrant growth of benign or malignant tumors in a subset of endocrine tissues. There are three major syndromes: MEN1, 2A and 2B. We describe a 60-year-old woman who initially manifested acute renal failure due to hypercalcemia and dehydration and, finally, was diagnosed as a sporadic MEN1 case.

Radiographic indices in one hundred fifty normal Iranian wrists.

BACKGROUND: Radiography is the most widely available imaging modality. Precise evaluations of wrist x-ray can help diagnosis and evaluate the prognosis of many wrist disorders. METHODS: We measured length, angles and indices in 150 posteroanterior and lateral wrist x-rays to determine normal dimensions and variations according to age and sex. All x-rays were made with standard exposure, with the wrist and forearm in a neutral position. RESULTS: The average carpal height ratio was 0.52±0.03 with the Youm method and 1.5±0.09 with the Nattrass method. Mean ulnar variance was +0.99±1.6 mm and mean radial inclination was 25±4 degrees. The average radial tilt was 10±5.1 degrees. Mean scapholunate angle was 50±8.4 degrees (normal range 40-60). CONCLUSION: Carpal height, third metacarpal and capitate length were smaller in women than in men. There was a significant positive relationship between all dimensions. Our data base may be used to follow-up in conditions such as carpal instability, osteoarthritis and osteonecrosis, as well as for clinical research.

Bilateral combined Monteggia and Galeazzi fractures: a case report.

We present an exceedingly rare case of left Monteggia-Galeazzi fracture-dislocation and right Monteggia-distal radius fracture occurring simultaneously in a 20-year old male patient who had fallen 13 meters from a building. The combination of Monteggia and Galeazzi fracture-dislocation in the same forearm is very rare and, to the best of our knowledge, simultaneous bilateral Monteggia and Galeazzi or distal radius fracture in the same patient, have never been reported.

Visual skills involved in decision making by expert referees.

Previous studies have compared visual skills of expert and novice athletes; referees' performance has not been addressed. Visual skills of two groups of expert referees, successful and unsuccessful in decision making, were compared. Using video clips of soccer matches to assess decision-making success of 41 national and international referees from 31 to 42 years of age, 10 top referees were selected as the Successful group and 10 as the Unsuccessful group. Visual tests included visual memory, visual reaction time, peripheral vision, recognition speed, saccadic eye movement, and facility of accommodation. The Successful group had better visual skills than the Unsuccessful group. Such visual skills enhance soccer referees' performance and may be recommended for young referees.